Early Revascularization Improves 1-Year Survival in MI With Cardiogenic Shock

Patients with acute myocardial infarction (AMI) complicated by cardiogenic shock have better survival at 1 year if they undergo early angioplasty or coronary bypass surgery, according to a report in The Journal of the American Medical Association for January 10.

As part of the SHOCK (SHould we emergently revascularize Occluded Coronaries for cardiogenic Shock) trial, Dr. Judith S. Hochman from St. Luke’s-Roosevelt Hospital Center, New York, and a multicenter group studied outcomes in 302 AMI patients with cardiogenic shock.

The researchers randomly assigned 150 patients to receive initial medical stabilization, which included thrombolysis, intra-aorta balloon counterpulsation and subsequent revascularization. The other 152 patients underwent revascularization within 6 hours of being randomized, with 55% undergoing angioplasty and 38% undergoing coronary artery bypass graft.

“What the study showed is that a very aggressive strategy of early coronary angiography, bypass surgery and angioplasty resulted in significantly improved 1-year survival,” Dr. Hochman told Reuters Health. In the patients who underwent early revascularization, 1-year survival was 46.7% compared with 33.6% for patients who received initial medical stabilization, according the report.

“Despite the fact that 1-year survival was improved,” Dr. Hochman added, “the short-term outcomes Äshow thatÅ the mortality rates were almost 50% both in the hospital and at 30 days. So these are very high-risk patients even with the procedure.” In addition, the researchers found that early revascularization was only of benefit to patients younger than 75 years of age.

Since 85% of the hospitals in the US do not have angioplasty or bypass surgery facilities, MI patients with cardiogenic shock should ideally be transferred very rapidly to tertiary care institutions, Dr. Hochman explained.

“Once shock develops you have to move very quickly and you have to have a system set up where you have identified a tertiary care center that is going to accept these patients, and you have to have a transport system that can handle it. The logistics and resources are a rate-limiting step,” she added.

“I don’t think that this means that more hospitals need to have angioplasty and bypass surgery available. Because these are the most complicated patients to manage, I firmly believe that regionalization with centers of excellence that handle many shock patients is the way to go,” Dr. Hochman told Reuters Health.

JAMA 2001;285:190-192.